Author: Dr Mark Toh, Consultant Clinical Psychologist

The 2nd Singapore Mental Health Study (SMHS) which began in 2016 (reported in December 2018) was initiated by the Institute of Mental Health (IMH) in collaboration with the Ministry of Health (MOH) and Nanyang Technological University (NTU). The study focused only on those 18 years old and above. The findings show that 13.9% or 1 in 7 Singaporeans have experienced a mood (major or bipolar depression), anxiety (obsessive compulsive disorder and generalised anxiety disorder) or alcohol use disorder (alcohol abuse and alcohol dependence) in their lifetime. These are the top 3 mental disorders in Singapore among the conditions assessed in the study. The study also reported that more than three-quarters of those with a mental disorder in their lifetime did not seek professional help. In the first SMHS study in 2010, the lifetime prevalence rate of mental disorders in the Singapore population was 12% or 1 in 8 persons. 

 

In a 2012 publication on Depression by the Ministry of Health, it was reported that depression affects between 2.5% to 18% of youth*. Depression among youths in Singapore is considered common. But it is a serious mental health symptom because of it what it reflects of children’s experiences in their environment. In particular, it is a serious reflection of what they may experience in the family or relational environment. If not adequately treated, the depressed child is likely to bring their depression into adulthood. This means that the emotionally wounded or damaged child is likely to carry their wounds forward as adults. This is a likely scenario because it is estimated that an initial episode of depression increases the likelihood of a second episode by 50%. A second major episode of depression increases the likelihood of a 3rd episode of depression by 75%. A third major episode of depression increases the likelihood of a 4th episode by 100%. Not surprisingly, depression has been found to affect brain structures and functioning. It is this recurrent tendency of depression that the suicide risk often increases over time within the same individual with a history of depression.

 

The risk of depression in childhood needs to be a major consideration for all those concerned with the development of children. Depression among children is a serious health problem because it can impair the emotional development of the child. It can seriously affect identity formation which is foundational to how the emerging adolescent learns to relate to themselves, to others and to the world at large. Later as adults, depression can impair psycho-social as well as occupational functioning. Depression is associated with significant morbidity and mortality. Also, depression can be triggered by, or lead to, other mental health conditions such as substance abuse, anxiety, schizophrenia or personality disorders.

 

Signs to watch for in children who may be depressed:

• Continuous feelings of sadness and hopelessness
• Irritability or anger
• Social withdrawal
• Increased sensitivity to rejection
• Changes in appetite — either increased or decreased
• Changes in sleep — sleeplessness or excessive sleep
• Vocal outbursts or crying
• Difficulty concentrating
• Fatigue and low energy
• Physical complaints such as stomachaches, headaches that do not respond to treatment
• Reduced ability to function during events and activities at home or with friends, in school, extracurricular activities, and in other hobbies or interests
• Feelings of worthlessness or guilt
• Impaired thinking or concentration
• Thoughts of death or suicide

 

Not all depressed children display these symptoms. They are more likely to display different symptoms at different times at different settings. When depression is significant, there are often noticeable changes in social activities, loss of interest in school and poor academic performance, or a change in appearance.

 

The young child is most vulnerable to depression due to the quality of relationships with his or her caregivers. This vulnerability increases when the family environment is also accompanied by marital conflict, abuse, violence, illness and/or low socioeconomic status. However, it is in the quality of relationships with caregivers that is crucial because of what it can offer as a buffer or protection from other external events or causes. Therefore, the mental health of children begins with thoughtful parents who genuinely understand and care about their child’s emotional needs and development.

Parenting Practices that promote Good Mental Health in Children:

1. Love your child unconditionally

• A genuine attitude to decide in the best interests of your child, and not in the parent’s convenience. Children thrive under certain physical and emotional conditions. The long-term view is needed. Parenting must understand the healthy outcome effective parenting can produce. This helps to plan to optimise the emotional development of the child. Loving well in the best interests of the child provides the best head start towards orienting the child to relate to themselves and others in a healthy way. Children’s need to establish a healthy identity, to uncover and stretch their potential, and learn to self-actualise will require parents to stretch their own emotional ‘ceiling.’ This means parents who desire to raise emotionally healthy children have to face their own insecurities so as not to impose them on their own children. Parenting with the best interests of the child will often be at the inconvenience of parents especially if parents do not appreciate the value of nurturing relationships which children thrive on.
  
• Loving your child well answers the deep longing for the child to later ask, “Am I worthwhile?” The need for children to recognise their own personal importance, value and worth prepares them to find that their later life will amount to significance. The child at risk of depression commonly struggle with this sense of self regard. Loving the child unconditionally is not based on the social or academic performance that society may hold out for children. Instead, mistakes are accepted as a natural part of their learning. If the parents placed their importance on their children only in reaching their own ambitions, or social or academic accomplishments, these indicate conditional expectations for them to find approval or acceptance. The will view their worth based on what they do instead of who they are. 

 

2. Ensure safe and secure physical and emotional surroundings

• Secure attachment, which is offering an ongoing, consistent, soothing, accepting presence to the infant is the important beginning in the parent-child relationship that helps the infant to learn to feel safe and secure in the world. This is a foundational need for positive mental health in infants and children and later adulthood. Emotional safety from the secure bond offered by a secure parent helps young children to trust the caregiver and to experience their world as safe and predictable. Through this quality of care, a child is encouraged to first accept themselves as as lovable, as important. It also prepares them next to want to explore their world as they mature physically. This means parents who wish the best for their children have to prepare them to become independent over time.
• Punitive, harsh or neglectful parents, especially when physical punishment is employed, leads to children questioning their worth or value and increases the risk for later depression. Parents who frequently employ shame, threats, insults or convey other derogatory messages to their children tend to raise a child who view themselves as defective. This is particularly damaging to children. Indeed, the DSM-V lists the sense of hopelessness or worthlessness as a common symptom of depression. Children can be raised to view themselves as defective, and that their life as meaningless.
• Promoting a safe emotional environment emphasises listening and empathy as skills, and being age-appropriate supportive as an attitude. Being emotionally present and listening well will foster the child’s wish to share their experiences. It builds on the bond already started from providing a secure attachment. It encourages children to view the parent and other people as a safe resource they can count on later if needed. It answers the important question that children ask, “Is it OK to be me?” This also fosters familiarity with emotional intimacy that better prepare children for friendships and significant relationships later. Familiarity with close and supportive relationships also mean that the child is less likely to isolate themselves socially when they face problems later on. It is a wise parent who value interactional activities with their young children early on rather than let them become overly attached to computer games and the internet to amuse themselves. Excessive computer use at the detriment of other activities has been linked to increased loneliness, poor social development and depression. 

 

3. Nurture Self-confidence and High Self-esteem

• Self-confidence is most easily found when children grow up feeling loved unconditionally.
• The foundation provided when the child feels loved should be supported by the child’s search for mastery in the world when they are ready to explore. Starting with simple activities, their need for autonomy and mastery over their environment allows them to gain confidence over the tasks they wish to take on. It is important for parents to support this rather than to over-protect them from exploration. Parents who are over-protective of their children and anxious about possible mishaps will find it difficult to foster the autonomy and independence their children need. To build their self-confidence and nurture high self-esteem, parents should be ready to praise their children’s exploratory efforts, be honest with them about their own mistakes, participate in the children’s  activities, encourage them in activities where their interests match their ambitions and allow them to be tested by the tasks they take on.
• The child’s ability to overcome, which allows them to be exposed to the frustrations and disappointments along the way, is something they have to face as well. Children should be encouraged to enjoy the process in the process of becoming. Learning to face their own frustrations, disappointments and failures will also serve to build self-confidence. Avoiding frustrations or disappointments or learning through determined effort and even failure tends to undermine self-confidence. The opportunities for children to grow through tasks and responsibilities is the beginning from which they can discover and establish their personal power and resilience.
• Looking for ways to nurture your child’s self-confidence and develop high esteem answers the child need to know “Can I do it?” It requires that parents focus on building strength or resilience through the children’s autonomy –their learning to exercise control over their environment– rather than emphasize ease or comfort through avoidance.

 

4. Promote opportunities to Play with other children and self

• Play is an integral part of emotional development of children. It is the primary means in which children learn to explore, to discover themselves in their world, and socially to cooperate, take turns and help in friendships. Studies have even suggested that inadequate play time for preschool children lead to more disruptive behaviour. Besides social interactions, play allows for the development of emotional awareness and fosters empathy where children learn about their own emotions as well as the emotions of others. Play also allows children to enjoy the process of becoming one self. This is important in a goal-oriented world that emphasises only winning or success or grades. Indeed they can discover the truth that frustrations and disappointments are often the price we all pay to achieve success. In so doing, play allows children to learn how to emotionally regulate their feelings when they are presented with opportunities to learn to express thoughts, feeling and behaviours in socially appropriate ways.
• Play is an important part of the child’s need to learn and experiment. Participation in play individually or in a group is an integral part of this learning process. Parents who are open to social interactions offer their children important advantages because they can facilitate their children’s emotional regulation and social learning when they play with their children on a regular basis. Children are more likely to enjoy other people contact when they already enjoy warm relationships with and have fun with their parents. TV or computer use should be monitored so that children are encouraged to engage more in active learning through participation. Computer games designers have made it easier for children, especially children who are neglected or are alone a lot, to be addicted to computer games. Excessive computer use has been found to be linked to depression in children.
• Play offers the opportunity to address the questions that children ask, “Am I OK and is it good to be me?

 

5. Provide appropriate guidance and discipline

• While children need to explore, develop new skills and become more independent and responsible, they also need to learn that certain behaviours are not acceptable. They need to be offered guidance and discipline that is fair and consistent from the family unit. They tend to take these social rules to their school and eventually to the workplace. Expectations may be expressed firmly but they need to be kind and realistic. Again, children learn best within encouraging and nurturing relationships. Parents need to be aware of their own maturity and growth and emotional status as they seek to help their children develop self-control, self-discipline or become kind. Their children cannot be expected to growth in those areas which parents have not grown themselves.
• Explain “why” the child is being disciplined and the consequences of their actions. Criticism should be focused on the behaviour and not the person. Threats, nagging and the use of threats should be avoided. The power that the parent wields should emphasise guidance and instruction in the best interests of the child that allow for children to learn from their mistakes. Those parents who practice excessive domination or coercion should understand that it is not helpful in the long run if children are forced to accept a place of surrender in order for them to survive in the relationship. They need to be encouraged to exercise their own power when appropriate. What has been described as authoritarian parenting, characterised by high demands with poor feedback or nurturance has also been found associated with a higher incidence of depression in children. This is in sharp contrast to authoritative parenting which is characterised by high demands accompanied by responsiveness to the child’s emotional needs. This approach is found to produce children who are responsible, they can regulate themselves, they can make good decisions on their own, and they are respectful to others and to rules.

 

Parenting is primarily a personal and emotional project in raising one’s children. It is foundationally an emotional process to secure the child before a young child eventually matures to believe in themselves. This is crucial before they begin to actively learn to navigate themselves in an increasingly complex world. It is widely understood as a parent’s most important life task since the emotional outcome show up in emotionally healthy or unhealthy individuals even before adulthood beckons. There is an emotional ‘birthing’ process where the Self of a child arrives at a healthy place in their identity formation. Or the opposite will happen. Quality parenting in this ‘birthing’ process create the foundation in which the next generation of children find the basis for their own survival, happiness and fulfilment. As such, parents learning to parent with optimal outcomes will do well to emotionally mature and be healthy themselves so that their children have the best chance to establish themselves in a healthy place in preparation to thrive in life. 

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References:

Institute of Mental Health, Latest nationwide study shows 1 in 7 people in Singapore has experienced a mental disorder in their lifetime, 2018. https://www.imh.com.sg/uploadedFiles/Newsroom/News_Releases/SMHS%202016_Media%20Release_FINAL_web%20upload.pdf

The Ministry of Health, Depression: MOH Clinical Practice Guidelines, 2011.

Woo BSC, Chang WC, Fung DSS, Koh JBK, Leong JSF, Kee CHY, et al. Development and validation of a depression scale for Asian adolescents. J Adolesc. 2004 Dec; 27(6):677-89.

Woo BSC, Ng TP, Fung DSS, Chan YH, Lee YP, Koh JBK, et al. Emotional and behavioral problems in Singaporean children based on parent, teacher and child reports. Singapore Med J. 2007 Dec; 48(12):1100-6.